Twenty-seven months into the COVID-19 pandemic, our defenses against the coronavirus seem at once stronger and more penetrable than ever. A growing majority of the U.S. population now has some immunity to SARS-CoV-2, the virus that causes COVID-19, whether from vaccination, past infection, or both. However, staggeringly infectious members of the Omicron family have demonstrated an ability to evade some of those protections. Since April, they have led to a quadrupling of daily coronavirus cases; the U.S. has been reporting more than a hundred thousand a day, but, because widely used at-home tests don’t show up in official tallies, the true number could be five or even ten times higher.
When the original Omicron, BA.1, swept the country this winter, it was by far the most contagious variant to date. But a subvariant that emerged more recently, BA.2, appears to be thirty per cent more transmissible, and one of its descendants, BA.2.12.1, is more contagious still. Unfortunately, people who have recovered from BA.1 infections can be reinfected by Omicron subvariants. According to some estimates, the U.S. could see a hundred million coronavirus infections this fall and winter. “This is approaching one of the most transmissible pathogens in history,” Eric Topol, the director of the Scripps Research Translational Institute, told me.
Yet the country’s response has been one of indifference. No state currently requires masks in public places, even though the director of the Centers for Disease Control and Prevention has said that a third of Americans should consider wearing them, and New York City recently recommended them indoors. When a judge struck down a federal mask requirement for trains and airplanes, the Biden Administration appealed, but did not seek to immediately reinstate the mandate. In April, less than a third of Americans said that they were even “somewhat worried” about getting COVID-19, the lowest proportion since July, 2021, and fewer people were socially distancing than at any time during the pandemic. A third of the population believes that the pandemic is over, including more than half of unvaccinated Americans and nearly six in ten Republicans.
This attitude is attributable, in part, to an indisputable reduction in the most serious consequences of COVID-19. Although new variants are causing more breakthrough infections, vaccines remain protective against severe illness. During the current surge, COVID deaths have been steady at around three hundred a day—still too many, but near pandemic lows—and hospitalizations have risen modestly. But our apathy also seems related to a pandemic malaise—an inability or unwillingness to devote more cognitive and material resources to a problem that refuses to leave us alone. Congress has so far failed to fund an adequate supply of vaccines, tests, and treatments this winter, suggesting that the country has retreated not only from controversial mandates but from the most basic tools of public health.
As a physician, I have struggled to know what to make of this moment in the pandemic, and I fear that it will last a long time. “We may be in this phase forever,” Robert Wachter, the chair of the department of medicine at the University of California, San Francisco, told me. Lately, I’ve been seeking out people who have shaped the COVID discourse—experts who have not only shared and interpreted information but helped to construct a pandemic narrative and, in doing so, influenced policymakers and the public. I wanted to understand how their thinking has changed on key questions now facing the country: How should we live? Who should decide? How long will this last? As the coronavirus has become less deadly yet more difficult to contain, they told me, strategies that defined the early pandemic have fallen away, and responsibility for our everyday behavior has shifted away from public-health officials and toward individuals. In the coming months, we’ll learn the consequences of this approach.
Doctors often categorize medical conditions as acute, subacute, or chronic. A patient with crushing chest pain and an alarming EKG is experiencing an acute emergency, meaning that, within minutes, they need a specific series of drugs and a team of medical professionals to unclog the culprit blood vessel. Another patient may feel his chest tighten when he walks up stairs, but the discomfort fades when he rests, and it’s been this way for years. His angina is said to be chronic: it’s serious and needs medical attention, but can usually be managed with medications and checkups. The subacute condition is somewhere in between. Last month, a man could climb three flights; last week, only two; and today, his torso feels heavy when he walks to the bathroom. Subacute illnesses are hazardous in their own way. They can often be mitigated if treated appropriately, but they may be difficult to diagnose, and, if you ignore or mismanage them, they can spiral out of control.
I sometimes think of this period as a subacute phase of the pandemic. COVID-19 is no longer an acute emergency, but it’s not yet clear how it will become an endemic disease that we are ready to live with. Public weariness, highly transmissible variants that evade some of our immunity—these factors may condemn us to intermittent surges long into the future. “Within the realm of my imagination, I can no longer see a true game changer that alters the fundamental dynamics from where we are today,” Wachter told me. “For me to say otherwise would be some combination of wishful thinking and reacting to my own internal pressure, and pressure from those around me, not to be a bummer.” This is, of course, a bummer. Still, it might not be as bad as it sounds. “We’re not going to see another million COVID deaths in the United States,” Wachter said. “The vast majority of severe illness will be fully preventable. We’ll probably wear masks in some places, maybe get regular boosters. It’s not the end of the world. It doesn’t diminish my life significantly.”
The experts I spoke to seemed to accept that, as a society, our options for containing such a transmissible virus are limited. “If cases were falling and there were not new variants that are so highly contagious, then suppressing infection would actually be a viable path,” Leana Wen, the former health commissioner of Baltimore, told me. “We have to recognize that the price of prioritizing low infection rates would be astronomical.” In her view, the U.S. can’t afford to close schools, restrict travel, or shutter businesses for long periods, and those stringent measures might not work anyway. “Even China, with the strictest lockdown in the world, is struggling to contain these hyper-contagious variants,” Devi Sridhar, a professor of public health at the University of Edinburgh and the author of “Preventable: How a Pandemic Changed the World and How to Stop the Next One,” told me. “We have to pivot away from the idea that we can avoid getting infected.”
Wen once advocated for strict measures to suppress the virus, but now argues for a return to something like normal life. She told me that she changed her mind in part because infections have grown less punishing with time, as more people acquire immunity and gain access to effective drugs. In two years, the infection fatality rate of SARS-CoV-2 has fallen dramatically. For people who’ve received a booster shot, it now really is on par with the flu. (Of course, the coronavirus is still infecting a lot more people.) As the risk of severe COVID-19 falls, Wen said, the threshold for policymakers to impose restrictions should rise. She argued that mandates would become appropriate only if a new and deadlier variant emerges. “Reintroducing them now would erode trust in public health and weaken our ability to respond to future emergencies,” she said. “As soon as the emergency fades, individual choice is again the key decider.”
Wen frequently hears the criticism, sometimes in the form of online vitriol, that her position does not fully account for the roughly seven million Americans who remain at higher risk for serious COVID-19, even after vaccination, because of compromised immune systems. Although she thinks that more should be done to protect the immunocompromised, she also believes that most Americans should be allowed to return to their pre-pandemic routines. In my clinical practice, I often care for immunocompromised patients who express fear and frustration that the country seems determined to move on from the pandemic—and, in their minds, to leave them behind. Having treated the devastating consequences of infections in these patients, I find it hard not to empathize with them, and I don’t have easy answers. Wachter told me that he is sympathetic to the idea that we’re not doing enough to protect vulnerable people—but in a country where many people don’t even have access to medical care, he said, “the idea that, all of a sudden, everyone in society is going to do everything possible . . . that strikes me as seeking a perfect world that we’re awfully far from.” In his view, “most immunocompromised people now have the tools to keep themselves relatively safe.” He pointed to vaccines, boosters, antivirals, N95 masks, and Evusheld, a preventive monoclonal antibody authorized for people who are moderately or severely immunocompromised. And, of course, we should all be encouraged to get tested and mask up before we spend time with someone who’s at high risk of a serious infection.
If we’re all likely to get COVID at some point, should everyone still try to avoid it? Wachter thinks so, and called for individuals to take precautions—masks, tests, steering clear of large indoor gatherings—in places where the coronavirus is highly prevalent. “For me at least, the long-COVID risk makes the benefits of reasonable amounts of caution outweigh the downsides, but I could see others making different choices,” he told me. “In the future, antivirals are likely to get better. Vaccines may be better. We’ll understand more about long COVID and how to manage it. At some point in my life, I know I’m going to get some terrible disease, whether COVID or something else. I’d like it to be as far down the road as possible.” He pointed to a recent estimate from the C.D.C. that nearly sixty per cent of Americans have been infected by the coronavirus, which suggests that more than a hundred million Americans have not.
The virus will continue to evolve, but so will our tools for fighting it. “It’s going to be innovation, not behavior change, that gets us out of this mess,” Topol, the Scripps director, told me. “You can’t keep people in a cave forever.” Topol fears that a future variant will be more virulent. “It pains me to say it, because I’m an optimist,” he said. But he argued that the U.S. still has the power to change the course of the pandemic, by continuing to invest in scientific research.
So far, new variants have tended to become more transmissible and better at getting around our immune defenses, but not more lethal. This makes sense from an evolutionary perspective—the virus faces selective pressure to find new ways to spread, not kill—and SARS-CoV-2 could go the way of other coronaviruses that cause the common cold. Then again, it might not. “People have this delusional idea that somehow the variants are just going to get milder over time—wrong!” Topol said. “They could easily become more pathogenic.” He pointed out that, compared with prior variants, Omicron has spawned more subvariants, which are chipping away at the “immunity wall” of vaccination.
In addition to advances such as better antiviral drugs, several types of vaccine innovations would be especially valuable. The first is a universal coronavirus vaccine. Such a vaccine could potentially give us some immunity against all SARS-CoV-2 variants, as well as other coronaviruses. (A research group at the California Institute of Technology, for example, has used a vaccine platform called a “mosaic nanoparticle,” which incorporates proteins from up to eight types of coronaviruses and has shown promising results in mice.) A second transformative innovation would be a vaccine that produces “sterilizing immunity”—that is, in its ideal form, an antibody response so potent that it prevents the pathogen from infecting and reproducing within us at all. This would dramatically slow the spread of the virus, but, for COVID-19 and many other pathogens, sterilizing vaccines have remained elusive. A vaccine that’s sprayed into the nose might be one path toward something closer to it. Because nasal vaccines produce high levels of antibodies inside the nose, where the virus often enters the body, they could be more effective at preventing infection altogether. There are now three such vaccine candidates in late-stage clinical trials; they present the body with many viral proteins, not just the spike, and could therefore produce broad, variant-resistant immunity. “Many people have needle-phobia and would probably say, I don’t want any more booster shots, but I wouldn’t mind taking a nasal spray every four-to-six months,” Topol told me. “We should be getting the nose and mouth Teflon-coated.” He’s troubled by a “profound lack of investment” in these kinds of advances.